Hypernatremia refers to elevated serum sodium levels, usually above 145 mEq/L. Typically, the client exhibits tented skin turgor and thirst in conjunction with dry, sticky mucous membranes, lethargy, and restlessness. Muscle weakness and paresthesia are associated with hypokalemia; fruity breath and Kussmaul’s respirations are associated with diabetic ketoacidosis. Muscle twitching and tetany may be seen with hypercalcemia or hyperphosphatemia.

Question 3

Which of the following conditions is an equal decrease of extracellular fluid (ECF) solute and water volume?

A

hypotonic FVD

B

isotonic FVD

C

hypertonic FVD

D

isotonic FVE

Question 3 Explanation:

Isotonic FVD involves an equal decrease in solute concentration and water volume.

Question 4

To determine if a patient’s respiratory system is functioning, the nurse would assess which of the following parameters:

A

respiratory rate

B

pulse

C

arterial blood gas

D

pulse oximetry

Question 4 Explanation:

Arterial blood gases will indicate CO2 and O2 levels. This is an indication that the respiratory system is functioning. Respiratory rate can reveal data about other systems, such as the brain, making letter c a better choice. Pulse rate is not measure of respiratory status. Pulse oximetry yields oxygen saturation levels, which is not a measure of acid-base balance.

Question 5

When assessing a patient for signs of fluid overload, the nurse would expect to observe:

A

bounding pulse

B

flat neck veins

C

poor skin turgor

D

vesicular

Question 5 Explanation:

Bounding pulse is a sign of fluid overload as more volume in the vessels causes a stronger sensation against the blood vessel walls. Flat neck veins and vesicular breath sounds are normal findings. Poor skin turgor is consistent with dehydration.

Question 6

When monitoring the daily weight of a patient with fluid volume deficit (FVD), the nurse is aware that fluid loss may be considered when weight loss begins to exceed:

A

0.25 lb

B

0.50 lb

C

1 lb

D

1 kg

Question 6 Explanation:

Weight loss of more than 0.50 lb. is considered to be fluid loss.

Question 7

Lisa, a client with altered urinary function, is under the care of nurse Tine. Which intervention is appropriate to include when developing a plan of care for Lisa who is experiencing urinary dribbling?

A

Inserting an indwelling Foley catheter

B

Having the client perform Kegel exercises

C

Keeping the skin clean and dry

D

Using pads or diapers on the client

Question 7 Explanation:

Kegel exercises, which help strengthen the muscles in the perineal area, are used to maintain urinary continence. To perform these exercises, the client tightens pelvic floor muscles for 4 seconds 10 times at least 20 times each day, stopping and starting the urinary flow. Inserting an indwelling Foley catheter increases the risk for infection and should be avoided. The nurse should encourage the client to develop a toileting schedule based on normal urinary habits. However, suggesting bathroom use every 8 hours may be too long an interval to wait. Pads or diapers should be used only as a resort.

Question 8

Marie Joy’s lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated?

A

Positive Trousseau’s sign

B

Positive Chvostek’s sign

C

Tetany

D

Paresthesia

Question 8 Explanation:

In a client with hypocalcemia, a positive Trousseau’s sign refers to carpopedal spasm that develops usually within 2 to 5 minutes after applying and inflating a blood pressure cuff to about 20 mm Hg higher than systolic pressure on the upper arm. This spasm occurs as the blood supply to the ulnar nerve is obstructed. Chvostek’s sign refers to twitching of the facial nerve when tapping below the earlobe. Paresthesia refers to the numbness or tingling. Tetany is a clinical manifestation of hypocalcemia denoted by tingling in the tips of the fingers around the mouth, and muscle spasms in the extremities and face.

Question 9

The physician has ordered IV replacement of potassium for a patient with severe hypokalemia. The nurse would administer this:

A

by rapid bolus

B

diluted in 100 cc over 1 hour

C

diluted in 10 cc over 10 minutes

D

IV push

Question 9 Explanation:

Potassium must be well diluted and given slowly because rapid administration will cause cardiac arrest.

Question 10

Nurse Katee is caring for Adam, a 22-year-old client, in a long-term facility. Which nursing intervention would be appropriate when identifying nursing interventions aimed at promoting and preventing contractures? Select all that apply.

A

Clustering activities to allow uninterrupted periods of rest

B

Maintaining correct body alignment at all times

C

Monitoring intake and output, using a urometer if necessary

D

Using a footboard or pillows to keep feet in correct position

E

Performing active and passive range-of-motion exercises

F

Weighing the client daily at the same time and in the same clothes

Question 10 Explanation:

Correct body alignment, preventing footdrop, and range-of-motion exercises will help prevent contractures. Clustering activities will help promote adequate rest. Monitoring intake and output and weighing the client will help maintain fluid and electrolyte balance.

Question 11

Which of the following intravenous solutions would be appropriate for a patient with severe hyponatremia secondary to syndrome of inappropriate antidiuretic hormone (SIADH)?

A

hypotonic solution

B

hypertonic solution

C

isotonic solution

D

normotonic solution

Question 11 Explanation:

When hyponatremia is severe, hypertonic solutions may be used but should be infused with caution due to the potential for development of CHF. In SIADH, isotonic and hypotonic solutions are not indicated, because urine output is minimal, so water is retained. this water retention dilutes serum sodium levels, making the patient hyponatremic and necessitating administration of hypertonic solutions to balance sodium and water. Normotonic solutions do not exist.

Question 12

Which of the following is the most important physical assessment parameter the nurse would consider when assessing fluid and electrolyte imbalance?

A

skin turgor

B

intake and output

C

osmotic pressure

D

cardiac rate and rhythm

Question 12 Explanation:

Cardiac rate and rhythm are the most important physical assessment parameter to measure. Skin turgor, intake and output are physical assessment parameters a nurse would consider when assessing fluid and electrolyte imbalance, but choice d is the most important.

Question 13

Mr. McPartlin suffered abrasions and lacerations after a vehicular accident. He was hospitalized and was treated for a couple of weeks. When planning care for a client with cellular injury, the nurse should consider which scientific rationale?

A

Nutritional needs remain unchanged for the well-nourished adult.

B

Age is an insignificant factor in cellular repair.

C

The presence of infection may slow the healing process.

D

Tissue with inadequate blood supply may heal faster.

Question 13 Explanation:

Infection impairs wound healing. Adequate blood supply is essential for healing. If inadequate, healing is slowed. Nutritional needs, including protein and caloric needs, increase for all clients undergoing cellular repair because adequate protein and caloric intake is essential to optimal cellular repair. Elderly clients may have decreased blood flow to the skin, organ atrophy and diminished function, and altered immunity. These conditions slow cellular repair and increase the risk of infection.

Question 14

A patient in which of the following disorders is at high risk to develop hypermagnesemia?

A

insulin shock

B

hyperadrenalism

C

nausea and vomiting

D

renal failure

Question 14 Explanation:

Renal failure can reduce magnesium excretion, leading to hypermagnesemia. Diabetic ketoacidosis, not insulin shock is a cause of hypermagnesemia. Hypoadrenalism, not hyperadrenalism is a cause of hypermagnesemia. Nausea and vomiting lead to hypomagnesemia.

Question 15

Which clinical manifestation would lead the nurse to suspect that a client is experiencing hypermagnesemia?

A

Muscle pain and acute rhabdomyolysis

B

Hot, flushed skin and diaphoresis

C

Soft-tissue calcification and hyperreflexia

D

Increased respiratory rate and depth

Question 15 Explanation:

Hypermagnesemia is manifested by hot, flushed skin and diaphoresis. The client also may exhibit hypotension, lethargy, drowsiness, and absent deep tendon reflexes. Muscle pain and acute rhabdomyolysis are indicative of hypophosphatemia. Soft-tissue calcification and hyperreflexia are indicative of hyperphosphatemia. Increased respiratory rate and depth are associated with metabolic acidosis.

Question 16

When assessing a patient for electrolyte balance, the nurse is aware that etiologies for hyponatremia include:

A

water gain

B

diuretic therapy

C

diaphoresis

D

all of the following

Question 16 Explanation:

Water gain, diuretic therapy, and diaphoresis are etiologies of hyponatremia.

Question 17

Normal serum sodium concentration ranges from:

A

120 to 125 mEq/L

B

125 to 130 mEq/L

C

136 to 145 mEq/L

D

140 to 148 mEq/L

Question 17 Explanation:

Normal serum sodium level ranges from 136 to 145 mEq/L.

Question 18

Mrs. dela Riva is in her first trimester of pregnancy. She has been lying all day because her OB-GYN requested her to have a complete bed rest. Which nursing intervention is appropriate when addressing the client’s need to maintain skin integrity?

A

Monitoring intake and output accurately

B

Instructing the client to cough and deep-breathe every 2 hours

C

Keeping the linens dry and wrinkle free

D

Using a foot board to maintain correct anatomic position

Question 18 Explanation:

Keeping the linens dry and wrinkle-free aids in preventing moisture and pressure from interfering with adequate blood supply to the tissues, helping to maintain skin integrity. Using a foot board is appropriate for maintaining normal body function position. Monitoring intake and output aids in assessing and maintaining bladder function.. Coughing and deep breathing help promote gas exchange.

Question 19

A 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to burn trauma. Which nursing intervention should be included for reducing pain due to cellular injury?

A 12-year-old boy was admitted in the hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing intervention should be included in the care of plan for the client?

A

Room temperature reduction

B

Fluid restriction of 2,000 ml/day

C

Axillary temperature measurements every 4 hours

D

Antiemetic agent administration

Question 20 Explanation:

For patient with hyperthermia, reducing the room temperature may help decrease the body temperature. Tepid baths, cool compresses, and cooling blanket may also be necessary. Antipyretics, and not antiemetics, are indicated to reduce fever. Oral or rectal temperature measurements are generally accepted and are more accurate than axillary measurements. Fluids should be encouraged, not restricted to compensate for insensible losses.

Question 21

Dietary recommendations for a patient with a hypotonic fluid excess should include:

A

decreased sodium intake

B

increased sodium intake

C

increased fluid intake

D

intake of potassium-rich foods

Question 21 Explanation:

Hypotonic fluid volume excess (FVE) involves an increase in water volume without an increase in sodium concentration. Increased sodium intake is part of the management of this condition.

Question 22

Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium?

A

14-year-old Elena who is taking diuretics

B

16-year-old John Joseph with ileostomy

C

16-year-old Gabriel with metabolic acidosis

D

18-year-old Albert who has renal disease

Question 22 Explanation:

Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Clients receiving diuretics, with ileostomies, or with metabolic acidosis may be hypokalemic and should be encouraged to eat foods high in potassium.

Question 23

Which of the following is not an appropriate nursing intervention for a patient with hypercalcemia?

A

administering calcitonin

B

administering calcium gluconate

C

administering loop diuretics

D

encouraging ambulation

Question 23 Explanation:

Calcium gluconate is used for replacement in deficiency states. Calcitonin and loop diuretics are used to lower serum calcium.

Question 24

Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is appropriate for maintaining normal bowel function?

A

Assessing dietary intake

B

Decreasing fluid intake

C

Providing limited physical activity

D

Turning, coughing, and deep breathing

Question 24 Explanation:

Assessing dietary intake provides a foundation for the client’s usual practices and may help determine if the client is prone to constipation or diarrhea. Limited physical activity may contribute to constipation due to decreased peristalsis. Turning, coughing and deep breathing help promote gas exchange. Fluid intake should be increased to aid bowel elimination.

Question 25

Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid?

A

Potassium

B

Phosphate

C

Chloride

D

Sodium

Question 25 Explanation:

Sodium is the electrolyte whose level is the primary determinant of the extracellular fluid concentration. Sodium a cation (e.g., positively charged ion), is the major electrolyte in extracellular fluid. Chloride, an anion (e.g., negatively charged ion), is also present in extracellular fluid, but to a lesser extent. Potassium (a cation) and phosphate (an anion) are the major electrolytes in the intracellular fluid.

Question 26

Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation. Which nursing intervention is the most appropriate for the client who is subsequently developing respiratory alkalosis?

A

Administering sodium chloride I.V.

B

Encouraging slow, deep breaths

C

Preparing to administer sodium bicarbonate

D

Administer low-flow oxygen therapy

Question 26 Explanation:

The client who is hyperventilating and subsequently develops respiratory alkalosis is losing too much carbon dioxide. Measures that result in the retention of carbon dioxide are needed. Encourage slow, deep breathing to retain carbon dioxide and reverse respiratory alkalosis. Administering low-flow oxygen therapy is appropriate for chronic respiratory acidosis. Administering sodium bicarbonate is appropriate for treating metabolic acidosis, and administering sodium chloride is appropriate for metabolic alkalosis.

Question 27

Which of the following conditions is associated with elevated serum chloride levels?

A

cystitis

B

diabetes

C

eclampsia

D

hypertension

Question 27 Explanation:

Eclampsia is associated with increased levels of serum chloride.

Question 28

Pierro was noted to be displaying facial grimaces after nurse Kara assessed his complaints of pain rated as 8 on a scale of 1 (no pain) 10 10 (worst pain). Which intervention should the nurse do?

A

Administering the client’s ordered pain medication immediately

B

Using guided imagery instead of administering pain medication

C

Using therapeutic conversation to try to discourage pain medication

D

Attempting to rule out complications before administering pain medication

Question 28 Explanation:

When intervening with a client complaining of pain, the nurse must always determine if the pain is expected pain or a complication that requires immediate nursing intervention. This must be done before administering the medication. Guided imagery should be used along with, not instead of, administration of pain medication. The nurse should medicate the client and not discourage medication.

Question 29

Jon has a potassium level of 6.5 mEq/L, which medication would nurse Wilma anticipate?

A

Potassium supplements

B

Kayexalate

C

Calcium gluconate

D

Sodium tablets

Question 29 Explanation:

The client’s potassium level is elevated; therefore, Kayexalate would be ordered to help reduce the potassium level. Kayexalate is a cation-exchange resin, which can be given orally, by nasogastric tube, or by retention enema. Potassium is drawn from the bowel and excreted through the feces. Because the client’s potassium level is already elevated, potassium supplements would not be given. Neither calcium gluconate nor sodium tablets would address the client’s elevated potassium level.

Question 30

Nursing interventions for a patient with hyponatremia include:

A

administering hypotonic IV fluids

B

encouraging water intake

C

restricting fluid intake

D

restricting sodium intake

Question 30 Explanation:

Hyponatremia involves a decreased concentration of sodium in relation to fluid volume, so restricting fluid intake is indicated.

Question 31

Etiologies associated with hypocalcemia may include all of the following except:

A

renal failure

B

inadequate intake calcium

C

metastatic bone lesions

D

vitamin D deficiency

Question 31 Explanation:

Metastatic bone lesions are associated with hypercalcemia due to accelerated bone metabolism and release of calcium into the serum. Renal failure, inadequate calcium intake, and vitamin D deficiency may cause hypocalcemia.

A client is diagnosed with metabolic acidosis, which would the nurse expect the health care provider to order?

A

Potassium

B

Sodium bicarbonate

C

Serum sodium level

D

Bronchodilator

Question 33 Explanation:

Metabolic acidosis results from excessive absorption or retention of acid or excessive excretion of bicarbonate. A base is needed. Sodium bicarbonate is a base and is used to treat documented metabolic acidosis. Potassium, serum sodium determinations, and a bronchodilator would be inappropriate orders for this client.

Question 34

Jeron is admitted in the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. Which goal is the most important for the client?

A

Prevention of fluid volume excess

B

Maintenance of adequate oxygenation

C

Education about infection prevention

D

Pain reduction

Question 34 Explanation:

For the client with asthma and infection, oxygenation is the priority. Maintaining adequate oxygenation reduces the risk of physiologic injury from cellular hypoxia, which is the leading cause of cell death. A fluid volume deficit resulting from fever and diaphoresis, not excess, is more likely for this client. No information regarding pain is provided in this scenario. Teaching about infection control is not appropriate at this time but would be appropriate before discharge.

Question 35

Which of the following findings would the nurse exp[ect to assess in a patient with hypokalemia?

A

hypertension

B

pH below 7.35

C

hypoglycemia

D

hyporeflexia

Question 35 Explanation:

Hyporeflexia is a symptom of hypokalemia

Question 36

Lee Angela’s lab test just revealed that her chloride level is 96 mEq/L. As a nurse, you would interpret this serum chloride level as:

A

high

B

low

C

within normal range

D

high normal

Question 36 Explanation:

Normal serum concentrations of chloride range from 95 to 108 mEq/L.

Question 37

Mr. Rogelio, a 32-year-old patient, is about to be discharged from the acute care setting. Which nursing intervention is the most important to include in the plan of care?

A

Stress-reduction techniques

B

Home environment evaluation

C

Skin-care measures

D

Participation in activities of daily living

Question 37 Explanation:

After discharge, the client is responsible for his own care and health maintenance management. Discharge includes assessing the home environment for determining the client’s ability to maintain his health at home.

Question 38

Tom is ready to be discharged from the medical-surgical unit after 5 days of hospitalization. Which client statement indicates to the nurse that Tom understands the discharge teaching about cellular injury?

A

“I do not have to see my doctor unless i have problems.”

B

“I can stop taking my antibiotics once I am feeling better.”

C

“If I have redness, drainage, or fever, I should call my healthcare provider.”

D

“If I have redness, drainage, or fever, I should call my healthcare provider.”

Question 38 Explanation:

Knowledge that redness, drainage, or fever — signs of infection associated with cellular injury — require reporting indicates that the client has understood the nurse’s discharge teaching. Follow-up checkups should be encouraged with an emphasis of antibiotic compliance even if the client feels better. There are usually activity limitations after cellular injury.

Question 39

Vien is receiving oral potassium supplements for his condition. How should the supplements be administered?

A

undiluted

B

diluted

C

on an empty stomach

D

at bedtime

Question 39 Explanation:

Oral potassium supplements are known to irritate gastrointestinal (GI) mucosa and should be diluted.

Question 40

In the extracellular fluid, chloride is a major:

A

compound

B

ion

C

anion

D

cation

Question 40 Explanation:

Chloride is a major anion found in the extracellular fluid. A compound occurs when two ions are bound together. Chloride is an ion, but this choice is too general. HCO3 is a cation.

Question 41

Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the client?

A

Sodium level

B

Magnesium level

C

Potassium level

D

Calcium level

Question 41 Explanation:

Diuretics such as furosemide may deplete serum potassium, leading to hypokalemia. When the client is also taking digoxin, the subsequent hypokalemia may potentiate the action of digoxin, placing the client at risk for digoxin toxicity. Diuretic therapy may lead to the loss of other electrolytes such as sodium, but the loss of potassium in association with digoxin therapy is most important. Hypocalcemia is usually associated with inadequate vitamin D intake or synthesis, renal failure, or use of drugs, such as aminoglycosides and corticosteroids. Hypomagnesemia generally is associated with poor nutrition, alcoholism, and excessive GI or renal losses, not diuretic therapy.

Question 42

Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and a bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse implement?

A

Instructing the client to breathe slowly into a paper bag

B

Administering low-flow oxygen

C

Encouraging the client to cough and deep breathe

D

Nothing, because these ABG values are within normal limits.

Question 42 Explanation:

The ABG results indicate respiratory acidosis requiring improved ventilation and increased oxygen to the lungs. Coughing and deep breathing can accomplish this. The nurse would administer high oxygen levels because the client does not have chronic obstructive pulmonary disease. Breathing into a paper bag is appropriate for a client hyperventilating and experiencing respiratory alkalosis. Some action is necessary, because the ABG results are not within normal limits.

Question 43

A rise in arterial pressure causes the baroreceptors and stretch receptors to signal an inhibition of the sympathetic nervous system, resulting in:

A

decreased sodium reabsorption

B

increased sodium reabsorption

C

decreased urine output

D

increased urine output

Question 43 Explanation:

Arterial baroreceptors and stretch receptors help maintain fluid balance by increasing urine output in response to a rise in arterial pressure.

Question 44

Aldosterone secretion in response to fluid loss will result in which one of the following electrolyte imbalances?

Respiratory regulation of acid-base balance involves the elimination or retention of carbon dioxide.

Question 46

A client with very dry mouth, skin and mucous membranes is diagnosed of having dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit?

A

Assessing urinary intake and output

B

Obtaining the client’s weight weekly at different times of the day

C

Monitoring arterial blood gas (ABG) results

D

Maintaining I.V. therapy at the keep-vein-open rate

Question 46 Explanation:

For the client with fluid volume deficit, assessing the client’s urine output (using a urometer if necessary) is essential to ensure an output of at least 30 ml/hour. The client should be weighed daily, not weekly, and at same time each day, usually in the morning. Monitoring ABGs is not necessary for this client. Rather, serum electrolyte levels would most likely be evaluated. The client also would have an I.V. rate at least 75 ml/hour, if not higher, to correct the fluid volume deficit.

Question 47

Insensible fluid losses include:

A

urine

B

gastric drainage

C

bleeding

D

perspiration

Question 47 Explanation:

Perspiration and the fluid lost via the lungs are termed insensible losses; normally, insensible losses equal about 1000 cc/day.

Question 48

Mr. Teban has a history of chronic obstructive pulmonary disease and has the following arterial blood gas results: partial pressure of oxygen (PO2), 55 mm Hg, and partial pressure of carbon dioxide (PCO2), 60 mm Hg. When attempting to improve the client’s blood gas values through improved ventilation and oxygen therapy, which is the client’s primary stimulus for breathing?

A

High PCO2

B

Low PO2

C

Normal pH

D

Normal bicarbonate (HCO3)

Question 48 Explanation:

A chronically elevated PCO2 level (above 50 mmHg) is associated with inadequate response of the respiratory center to plasma carbon dioxide. The major stimulus to breathing then becomes hypoxia (low PO2). High PCO2 and normal pH and HCO3 levels would not be the primary stimuli for breathing in this client.

Question 49

For a patient with hypomagnesemia, which of the following medications may become toxic?

A

Lasix

B

Digoxin

C

calcium gluconate

D

CAPD

Question 49 Explanation:

In hypomagnesemia, a patient on digoxin is likely to develop digitalis toxicity. Neither A nor C has toxicity as a side effect. CAPD is not a medication.

Question 50

Osmotic pressure is created through the process of:

A

osmosis

B

diffusion

C

filtration

D

capillary dynamics

Question 50 Explanation:

In diffusion, the solute moves from an area of higher concentration to one of lower concentration, creating osmotic pressure. Osmotic pressure is related to the process of osmosis. Filtration is created by hydrostatic pressure. Capillary dynamics are related to fluid exchange at the intravascular and interstitial levels.

Question 51

Khaleesi is admitted in the hospital due to having lower than normal potassium level in her bloodstream. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase?

A

Whole grains and nuts

B

Milk products and green, leafy vegetables

C

Pork products and canned vegetables

D

Orange juice and bananas

Question 51 Explanation:

The client with hypokalemia needs to increase the intake of foods high in potassium. Orange juice and bananas are high in potassium, along with raisins, apricots, avocados, beans, and potatoes. Whole grains and nuts would be encouraged for the client with hypomagnesemia; milk products and green, leafy vegetables are good sources of calcium for the client with hypocalcemia. Pork products and canned vegetables are high in sodium and are encouraged for the client with hyponatremia.

Question 52

The nurse would analyze an arterial pH of 7.46 as indicating:

A

acidosis

B

alkalosis

C

homeostasis

D

neutrality

Question 52 Explanation:

Alkalosis is indicated by a pH above 7.45.

Question 53

Nurse Marthia is teaching her students about bacterial control. Which intervention is the most important factor in preventing the spread of microorganism?

A

Maintenance of asepsis with indwelling catheter insertion

B

Use of masks, gowns, and gloves when caring for clients with infection

C

Correct handwashing technique

D

Cleanup of blood spills with sodium hydrochloride

Question 53 Explanation:

Handwashing remains the most effective procedure for controlling microorganisms and the incidence of nosocomial infections. Aseptic technique is essential with invasive procedures, including indwelling catheters. Masks, gowns, and gloves are necessary only when the likelihood of exposure to blood or body fluids is high. Spills of blood from clients with acquired immunodeficiency syndrome should be cleaned with sodium hydrochloride.

Question 54

A patient with tented skin turgor, dry mucous membranes, and decreased urinary output is under nurse Mark’s care. Which nursing intervention should be included the care plan of Mark for his patient?

A

Administering I.V. and oral fluids

B

Clustering necessary activities throughout the day

C

Assessing color, odor, and amount of sputum

D

Monitoring serum albumin and total protein levels

Question 54 Explanation:

The client’s assessment findings would lead the nurse to suspect that the client is dehydrated. Administering I.V. fluids is appropriate. Assessing sputum would be appropriate for a client with problems associated with impaired gas exchange or ineffective airway clearance. Monitoring albumin and protein levels is appropriate for clients experiencing inadequate nutrition. Clustering activities helps with energy conservation and promotes rest.

Question 55

Nursing interventions for a patient with hypermagnesemia include administering calcium gluconate to:

A

increase calcium levels

B

antagonize the cardiac effects of magnesium

C

lower calcium levels

D

lower magnesium levels

Question 55 Explanation:

In a patient with hypermagnesemia, administration of calcium gluconate will antagonize the cardiac effects of magnesium. Although calcium gluconate will raise serum calcium levels, that is not the purpose of administration. Calcium gluconate does not lower calcium or magnesium levels.

Question 56

Nurse John Joseph is totaling the intake and output for Elena Reyes, a client diagnosed with septicemia who is on a clear liquid diet. The client intakes 8 oz of apple juice, 850 ml of water, 2 cups of beef broth, and 900 ml of half-normal saline solution and outputs 1,500 ml of urine during the shift. How many milliliters should the nurse document as the client’s intake.

A

2,230

B

2,740

C

2,470

D

2,320

Question 56 Explanation:

The fluid intake includes 8 oz (240 ml) of apple juice, 850 ml of water, 2 cups (480 ml) of beef broth, and 900 ml of I.V. fluid for a total of 2,470 ml intake for the shift.

Question 57

Maya, who is admitted in a hospital, is scheduled to have her general checkup and physical assessment. Nurse Timothy observed a reddened area over her left hip. Which should the nurse do first?

A

Massage the reddened are for a few minutes

B

Notify the physician immediately

C

Arrange for a pressure-relieving device

D

Turn the client to the right side for 2 hours

Question 57 Explanation:

Turning the client to the right side relieves the pressure and promotes adequate blood supply to the left hip. A reddened area is never massaged, because this may increase the damage to the already reddened, damaged area. The health care provider does not need to be notified immediately. However, the health care provider should be informed of this finding the next time he is on the unit. Arranging for a pressure-relieving device is appropriate, but this is done after the client has been turned.

Question 58

Nursing intervention for the patient with hyperphosphatemia include encouraging intake of:

A

amphogel

B

Fleets phospho-soda

C

milk

D

vitamin D

Question 58 Explanation:

Administration of phosphate binders (amphogel and basagel) will reduce the serum phosphate levels.

Question 59

Genevieve is diagnosed with hypomagnesemia, which nursing intervention would be appropriate?

A

Instituting seizure precaution to prevent injury

B

Instructing the client on the importance of preventing infection

C

Avoiding the use of tight tourniquet when drawing blood

D

Teaching the client the importance of early ambulation

Question 59 Explanation:

Instituting seizure precaution is an appropriate intervention, because the client with hypomagnesemia is at risk for seizures. Hypophosphatemia may produce changes in granulocytes, which would require the nurse to instruct the client about measures to prevent infection. Avoiding the use of a tight tourniquet when drawing blood helps prevent pseudohyperkalemia. Early ambulation is recommended to reduce calcium loss from bones during hospitalization.

Question 60

A 36-year-old male client is about to be discharged from the the hospital after 5 days due to surgery. Which intervention should be included in the home health care nurse’s instructions about measures to prevent constipation?

A

Discouraging the client from eating large amounts of roughage-containing foods in the diet.

B

Encouraging the client to use laxatives routinely to ensure adequate bowel elimination.

C

Instructing the client to establish a bowel evacuation schedule that changes every day.

D

Instructing the client to fill a 2-L bottle with water every night and drink it the next day.

Question 60 Explanation:

Adequate fluids and fiber in the diet are key to preventing constipation. Having the client fill a 2-L bottle with water every night and drink it the next day is one method for ensuring the client receives at least 2,000 ml of water daily. The client also should be instructed to drink any other fluids throughout the day. High fiber or roughage foods are encouraged. Laxatives should not be used routinely for bowel elimination. They should be used only as a last resort, because clients may become dependent on them. A regular bowel evacuation schedule should be established.

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NCLEX Practice Exam for Fluids, Electrolytes & Homeostasis 1 (EM)*

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In diffusion, the solute moves from an area of higher concentration to one of lower concentration, creating osmotic pressure. Osmotic pressure is related to the process of osmosis. Filtration is created by hydrostatic pressure. Capillary dynamics are related to fluid exchange at the intravascular and interstitial levels.

Question 3

Which clinical manifestation would lead the nurse to suspect that a client is experiencing hypermagnesemia?

A

Muscle pain and acute rhabdomyolysis

B

Hot, flushed skin and diaphoresis

C

Soft-tissue calcification and hyperreflexia

D

Increased respiratory rate and depth

Question 3 Explanation:

Hypermagnesemia is manifested by hot, flushed skin and diaphoresis. The client also may exhibit hypotension, lethargy, drowsiness, and absent deep tendon reflexes. Muscle pain and acute rhabdomyolysis are indicative of hypophosphatemia. Soft-tissue calcification and hyperreflexia are indicative of hyperphosphatemia. Increased respiratory rate and depth are associated with metabolic acidosis.

Question 4

Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation. Which nursing intervention is the most appropriate for the client who is subsequently developing respiratory alkalosis?

A

Administering sodium chloride I.V.

B

Encouraging slow, deep breaths

C

Preparing to administer sodium bicarbonate

D

Administer low-flow oxygen therapy

Question 4 Explanation:

The client who is hyperventilating and subsequently develops respiratory alkalosis is losing too much carbon dioxide. Measures that result in the retention of carbon dioxide are needed. Encourage slow, deep breathing to retain carbon dioxide and reverse respiratory alkalosis. Administering low-flow oxygen therapy is appropriate for chronic respiratory acidosis. Administering sodium bicarbonate is appropriate for treating metabolic acidosis, and administering sodium chloride is appropriate for metabolic alkalosis.

Question 5

A client is diagnosed with metabolic acidosis, which would the nurse expect the health care provider to order?

A

Potassium

B

Sodium bicarbonate

C

Serum sodium level

D

Bronchodilator

Question 5 Explanation:

Metabolic acidosis results from excessive absorption or retention of acid or excessive excretion of bicarbonate. A base is needed. Sodium bicarbonate is a base and is used to treat documented metabolic acidosis. Potassium, serum sodium determinations, and a bronchodilator would be inappropriate orders for this client.

Question 6

The nurse would analyze an arterial pH of 7.46 as indicating:

A

acidosis

B

alkalosis

C

homeostasis

D

neutrality

Question 6 Explanation:

Alkalosis is indicated by a pH above 7.45.

Question 7

Nurse Katee is caring for Adam, a 22-year-old client, in a long-term facility. Which nursing intervention would be appropriate when identifying nursing interventions aimed at promoting and preventing contractures? Select all that apply.

A

Clustering activities to allow uninterrupted periods of rest

B

Maintaining correct body alignment at all times

C

Monitoring intake and output, using a urometer if necessary

D

Using a footboard or pillows to keep feet in correct position

E

Performing active and passive range-of-motion exercises

F

Weighing the client daily at the same time and in the same clothes

Question 7 Explanation:

Correct body alignment, preventing footdrop, and range-of-motion exercises will help prevent contractures. Clustering activities will help promote adequate rest. Monitoring intake and output and weighing the client will help maintain fluid and electrolyte balance.

Question 8

Vien is receiving oral potassium supplements for his condition. How should the supplements be administered?

A

undiluted

B

diluted

C

on an empty stomach

D

at bedtime

Question 8 Explanation:

Oral potassium supplements are known to irritate gastrointestinal (GI) mucosa and should be diluted.

Question 9

Which of the following conditions is an equal decrease of extracellular fluid (ECF) solute and water volume?

A

hypotonic FVD

B

isotonic FVD

C

hypertonic FVD

D

isotonic FVE

Question 9 Explanation:

Isotonic FVD involves an equal decrease in solute concentration and water volume.

Question 10

Normal serum sodium concentration ranges from:

A

120 to 125 mEq/L

B

125 to 130 mEq/L

C

136 to 145 mEq/L

D

140 to 148 mEq/L

Question 10 Explanation:

Normal serum sodium level ranges from 136 to 145 mEq/L.

Question 11

Genevieve is diagnosed with hypomagnesemia, which nursing intervention would be appropriate?

A

Instituting seizure precaution to prevent injury

B

Instructing the client on the importance of preventing infection

C

Avoiding the use of tight tourniquet when drawing blood

D

Teaching the client the importance of early ambulation

Question 11 Explanation:

Instituting seizure precaution is an appropriate intervention, because the client with hypomagnesemia is at risk for seizures. Hypophosphatemia may produce changes in granulocytes, which would require the nurse to instruct the client about measures to prevent infection. Avoiding the use of a tight tourniquet when drawing blood helps prevent pseudohyperkalemia. Early ambulation is recommended to reduce calcium loss from bones during hospitalization.

Question 12

Which of the following is the most important physical assessment parameter the nurse would consider when assessing fluid and electrolyte imbalance?

A

skin turgor

B

intake and output

C

osmotic pressure

D

cardiac rate and rhythm

Question 12 Explanation:

Cardiac rate and rhythm are the most important physical assessment parameter to measure. Skin turgor, intake and output are physical assessment parameters a nurse would consider when assessing fluid and electrolyte imbalance, but choice d is the most important.

Question 13

When assessing a patient for electrolyte balance, the nurse is aware that etiologies for hyponatremia include:

A

water gain

B

diuretic therapy

C

diaphoresis

D

all of the following

Question 13 Explanation:

Water gain, diuretic therapy, and diaphoresis are etiologies of hyponatremia.

Question 14

Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium?

A

14-year-old Elena who is taking diuretics

B

16-year-old John Joseph with ileostomy

C

16-year-old Gabriel with metabolic acidosis

D

18-year-old Albert who has renal disease

Question 14 Explanation:

Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Clients receiving diuretics, with ileostomies, or with metabolic acidosis may be hypokalemic and should be encouraged to eat foods high in potassium.

Question 15

Which of the following intravenous solutions would be appropriate for a patient with severe hyponatremia secondary to syndrome of inappropriate antidiuretic hormone (SIADH)?

A

hypotonic solution

B

hypertonic solution

C

isotonic solution

D

normotonic solution

Question 15 Explanation:

When hyponatremia is severe, hypertonic solutions may be used but should be infused with caution due to the potential for development of CHF. In SIADH, isotonic and hypotonic solutions are not indicated, because urine output is minimal, so water is retained. this water retention dilutes serum sodium levels, making the patient hyponatremic and necessitating administration of hypertonic solutions to balance sodium and water. Normotonic solutions do not exist.

Question 16

Jeron is admitted in the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. Which goal is the most important for the client?

A

Prevention of fluid volume excess

B

Maintenance of adequate oxygenation

C

Education about infection prevention

D

Pain reduction

Question 16 Explanation:

For the client with asthma and infection, oxygenation is the priority. Maintaining adequate oxygenation reduces the risk of physiologic injury from cellular hypoxia, which is the leading cause of cell death. A fluid volume deficit resulting from fever and diaphoresis, not excess, is more likely for this client. No information regarding pain is provided in this scenario. Teaching about infection control is not appropriate at this time but would be appropriate before discharge.

Question 17

A patient with tented skin turgor, dry mucous membranes, and decreased urinary output is under nurse Mark’s care. Which nursing intervention should be included the care plan of Mark for his patient?

A

Administering I.V. and oral fluids

B

Clustering necessary activities throughout the day

C

Assessing color, odor, and amount of sputum

D

Monitoring serum albumin and total protein levels

Question 17 Explanation:

The client’s assessment findings would lead the nurse to suspect that the client is dehydrated. Administering I.V. fluids is appropriate. Assessing sputum would be appropriate for a client with problems associated with impaired gas exchange or ineffective airway clearance. Monitoring albumin and protein levels is appropriate for clients experiencing inadequate nutrition. Clustering activities helps with energy conservation and promotes rest.

Question 18

Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid?

A

Potassium

B

Phosphate

C

Chloride

D

Sodium

Question 18 Explanation:

Sodium is the electrolyte whose level is the primary determinant of the extracellular fluid concentration. Sodium a cation (e.g., positively charged ion), is the major electrolyte in extracellular fluid. Chloride, an anion (e.g., negatively charged ion), is also present in extracellular fluid, but to a lesser extent. Potassium (a cation) and phosphate (an anion) are the major electrolytes in the intracellular fluid.

Question 19

In the extracellular fluid, chloride is a major:

A

compound

B

ion

C

anion

D

cation

Question 19 Explanation:

Chloride is a major anion found in the extracellular fluid. A compound occurs when two ions are bound together. Chloride is an ion, but this choice is too general. HCO3 is a cation.

Question 20

Mr. Rogelio, a 32-year-old patient, is about to be discharged from the acute care setting. Which nursing intervention is the most important to include in the plan of care?

A

Stress-reduction techniques

B

Home environment evaluation

C

Skin-care measures

D

Participation in activities of daily living

Question 20 Explanation:

After discharge, the client is responsible for his own care and health maintenance management. Discharge includes assessing the home environment for determining the client’s ability to maintain his health at home.

Question 21

Which of the following is not an appropriate nursing intervention for a patient with hypercalcemia?

A

administering calcitonin

B

administering calcium gluconate

C

administering loop diuretics

D

encouraging ambulation

Question 21 Explanation:

Calcium gluconate is used for replacement in deficiency states. Calcitonin and loop diuretics are used to lower serum calcium.

Question 22

A client with very dry mouth, skin and mucous membranes is diagnosed of having dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit?

A

Assessing urinary intake and output

B

Obtaining the client’s weight weekly at different times of the day

C

Monitoring arterial blood gas (ABG) results

D

Maintaining I.V. therapy at the keep-vein-open rate

Question 22 Explanation:

For the client with fluid volume deficit, assessing the client’s urine output (using a urometer if necessary) is essential to ensure an output of at least 30 ml/hour. The client should be weighed daily, not weekly, and at same time each day, usually in the morning. Monitoring ABGs is not necessary for this client. Rather, serum electrolyte levels would most likely be evaluated. The client also would have an I.V. rate at least 75 ml/hour, if not higher, to correct the fluid volume deficit.

Question 23

Tom is ready to be discharged from the medical-surgical unit after 5 days of hospitalization. Which client statement indicates to the nurse that Tom understands the discharge teaching about cellular injury?

A

“I do not have to see my doctor unless i have problems.”

B

“I can stop taking my antibiotics once I am feeling better.”

C

“If I have redness, drainage, or fever, I should call my healthcare provider.”

D

“If I have redness, drainage, or fever, I should call my healthcare provider.”

Question 23 Explanation:

Knowledge that redness, drainage, or fever — signs of infection associated with cellular injury — require reporting indicates that the client has understood the nurse’s discharge teaching. Follow-up checkups should be encouraged with an emphasis of antibiotic compliance even if the client feels better. There are usually activity limitations after cellular injury.

Question 24

For a patient with hypomagnesemia, which of the following medications may become toxic?

A

Lasix

B

Digoxin

C

calcium gluconate

D

CAPD

Question 24 Explanation:

In hypomagnesemia, a patient on digoxin is likely to develop digitalis toxicity. Neither A nor C has toxicity as a side effect. CAPD is not a medication.

Question 25

A 36-year-old male client is about to be discharged from the the hospital after 5 days due to surgery. Which intervention should be included in the home health care nurse’s instructions about measures to prevent constipation?

A

Discouraging the client from eating large amounts of roughage-containing foods in the diet.

B

Encouraging the client to use laxatives routinely to ensure adequate bowel elimination.

C

Instructing the client to establish a bowel evacuation schedule that changes every day.

D

Instructing the client to fill a 2-L bottle with water every night and drink it the next day.

Question 25 Explanation:

Adequate fluids and fiber in the diet are key to preventing constipation. Having the client fill a 2-L bottle with water every night and drink it the next day is one method for ensuring the client receives at least 2,000 ml of water daily. The client also should be instructed to drink any other fluids throughout the day. High fiber or roughage foods are encouraged. Laxatives should not be used routinely for bowel elimination. They should be used only as a last resort, because clients may become dependent on them. A regular bowel evacuation schedule should be established.

Question 26

Nurse John Joseph is totaling the intake and output for Elena Reyes, a client diagnosed with septicemia who is on a clear liquid diet. The client intakes 8 oz of apple juice, 850 ml of water, 2 cups of beef broth, and 900 ml of half-normal saline solution and outputs 1,500 ml of urine during the shift. How many milliliters should the nurse document as the client’s intake.

A

2,230

B

2,740

C

2,470

D

2,320

Question 26 Explanation:

The fluid intake includes 8 oz (240 ml) of apple juice, 850 ml of water, 2 cups (480 ml) of beef broth, and 900 ml of I.V. fluid for a total of 2,470 ml intake for the shift.

Question 27

The physician has ordered IV replacement of potassium for a patient with severe hypokalemia. The nurse would administer this:

A

by rapid bolus

B

diluted in 100 cc over 1 hour

C

diluted in 10 cc over 10 minutes

D

IV push

Question 27 Explanation:

Potassium must be well diluted and given slowly because rapid administration will cause cardiac arrest.

Question 28

Which of the following findings would the nurse exp[ect to assess in a patient with hypokalemia?

Hypernatremia refers to elevated serum sodium levels, usually above 145 mEq/L. Typically, the client exhibits tented skin turgor and thirst in conjunction with dry, sticky mucous membranes, lethargy, and restlessness. Muscle weakness and paresthesia are associated with hypokalemia; fruity breath and Kussmaul’s respirations are associated with diabetic ketoacidosis. Muscle twitching and tetany may be seen with hypercalcemia or hyperphosphatemia.

Question 30

Nursing interventions for a patient with hyponatremia include:

A

administering hypotonic IV fluids

B

encouraging water intake

C

restricting fluid intake

D

restricting sodium intake

Question 30 Explanation:

Hyponatremia involves a decreased concentration of sodium in relation to fluid volume, so restricting fluid intake is indicated.

Question 31

Pierro was noted to be displaying facial grimaces after nurse Kara assessed his complaints of pain rated as 8 on a scale of 1 (no pain) 10 10 (worst pain). Which intervention should the nurse do?

A

Administering the client’s ordered pain medication immediately

B

Using guided imagery instead of administering pain medication

C

Using therapeutic conversation to try to discourage pain medication

D

Attempting to rule out complications before administering pain medication

Question 31 Explanation:

When intervening with a client complaining of pain, the nurse must always determine if the pain is expected pain or a complication that requires immediate nursing intervention. This must be done before administering the medication. Guided imagery should be used along with, not instead of, administration of pain medication. The nurse should medicate the client and not discourage medication.

Question 32

Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and a bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse implement?

A

Instructing the client to breathe slowly into a paper bag

B

Administering low-flow oxygen

C

Encouraging the client to cough and deep breathe

D

Nothing, because these ABG values are within normal limits.

Question 32 Explanation:

The ABG results indicate respiratory acidosis requiring improved ventilation and increased oxygen to the lungs. Coughing and deep breathing can accomplish this. The nurse would administer high oxygen levels because the client does not have chronic obstructive pulmonary disease. Breathing into a paper bag is appropriate for a client hyperventilating and experiencing respiratory alkalosis. Some action is necessary, because the ABG results are not within normal limits.

Question 33

Which of the following findings would the nurse expect to asses in hypercalcemia?

A

prolonged QRS complex

B

tetany

C

petechiae

D

urinary calculi

Question 33 Explanation:

Urinary calculi may occur with hypercalcemia. Shortened, not prolonged QRS complex would be seen in hypercalcemia. Tetany and petechiae are signs of hypocalcemia.

Question 34

Lee Angela’s lab test just revealed that her chloride level is 96 mEq/L. As a nurse, you would interpret this serum chloride level as:

A

high

B

low

C

within normal range

D

high normal

Question 34 Explanation:

Normal serum concentrations of chloride range from 95 to 108 mEq/L.

Question 35

When assessing a patient for signs of fluid overload, the nurse would expect to observe:

A

bounding pulse

B

flat neck veins

C

poor skin turgor

D

vesicular

Question 35 Explanation:

Bounding pulse is a sign of fluid overload as more volume in the vessels causes a stronger sensation against the blood vessel walls. Flat neck veins and vesicular breath sounds are normal findings. Poor skin turgor is consistent with dehydration.

Question 36

When monitoring the daily weight of a patient with fluid volume deficit (FVD), the nurse is aware that fluid loss may be considered when weight loss begins to exceed:

A

0.25 lb

B

0.50 lb

C

1 lb

D

1 kg

Question 36 Explanation:

Weight loss of more than 0.50 lb. is considered to be fluid loss.

Question 37

To determine if a patient’s respiratory system is functioning, the nurse would assess which of the following parameters:

A

respiratory rate

B

pulse

C

arterial blood gas

D

pulse oximetry

Question 37 Explanation:

Arterial blood gases will indicate CO2 and O2 levels. This is an indication that the respiratory system is functioning. Respiratory rate can reveal data about other systems, such as the brain, making letter c a better choice. Pulse rate is not measure of respiratory status. Pulse oximetry yields oxygen saturation levels, which is not a measure of acid-base balance.

Question 38

Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is appropriate for maintaining normal bowel function?

A

Assessing dietary intake

B

Decreasing fluid intake

C

Providing limited physical activity

D

Turning, coughing, and deep breathing

Question 38 Explanation:

Assessing dietary intake provides a foundation for the client’s usual practices and may help determine if the client is prone to constipation or diarrhea. Limited physical activity may contribute to constipation due to decreased peristalsis. Turning, coughing and deep breathing help promote gas exchange. Fluid intake should be increased to aid bowel elimination.

Question 39

Respiratory regulation of acids and bases involves:

A

hydrogen

B

hydroxide

C

oxygen

D

carbon dioxide

Question 39 Explanation:

Respiratory regulation of acid-base balance involves the elimination or retention of carbon dioxide.

Question 40

Insensible fluid losses include:

A

urine

B

gastric drainage

C

bleeding

D

perspiration

Question 40 Explanation:

Perspiration and the fluid lost via the lungs are termed insensible losses; normally, insensible losses equal about 1000 cc/day.

Question 41

Jon has a potassium level of 6.5 mEq/L, which medication would nurse Wilma anticipate?

A

Potassium supplements

B

Kayexalate

C

Calcium gluconate

D

Sodium tablets

Question 41 Explanation:

The client’s potassium level is elevated; therefore, Kayexalate would be ordered to help reduce the potassium level. Kayexalate is a cation-exchange resin, which can be given orally, by nasogastric tube, or by retention enema. Potassium is drawn from the bowel and excreted through the feces. Because the client’s potassium level is already elevated, potassium supplements would not be given. Neither calcium gluconate nor sodium tablets would address the client’s elevated potassium level.

Question 42

A patient in which of the following disorders is at high risk to develop hypermagnesemia?

A

insulin shock

B

hyperadrenalism

C

nausea and vomiting

D

renal failure

Question 42 Explanation:

Renal failure can reduce magnesium excretion, leading to hypermagnesemia. Diabetic ketoacidosis, not insulin shock is a cause of hypermagnesemia. Hypoadrenalism, not hyperadrenalism is a cause of hypermagnesemia. Nausea and vomiting lead to hypomagnesemia.

Question 43

Nurse Marthia is teaching her students about bacterial control. Which intervention is the most important factor in preventing the spread of microorganism?

A

Maintenance of asepsis with indwelling catheter insertion

B

Use of masks, gowns, and gloves when caring for clients with infection

C

Correct handwashing technique

D

Cleanup of blood spills with sodium hydrochloride

Question 43 Explanation:

Handwashing remains the most effective procedure for controlling microorganisms and the incidence of nosocomial infections. Aseptic technique is essential with invasive procedures, including indwelling catheters. Masks, gowns, and gloves are necessary only when the likelihood of exposure to blood or body fluids is high. Spills of blood from clients with acquired immunodeficiency syndrome should be cleaned with sodium hydrochloride.

Question 44

Mrs. dela Riva is in her first trimester of pregnancy. She has been lying all day because her OB-GYN requested her to have a complete bed rest. Which nursing intervention is appropriate when addressing the client’s need to maintain skin integrity?

A

Monitoring intake and output accurately

B

Instructing the client to cough and deep-breathe every 2 hours

C

Keeping the linens dry and wrinkle free

D

Using a foot board to maintain correct anatomic position

Question 44 Explanation:

Keeping the linens dry and wrinkle-free aids in preventing moisture and pressure from interfering with adequate blood supply to the tissues, helping to maintain skin integrity. Using a foot board is appropriate for maintaining normal body function position. Monitoring intake and output aids in assessing and maintaining bladder function.. Coughing and deep breathing help promote gas exchange.

Question 45

Mr. Teban has a history of chronic obstructive pulmonary disease and has the following arterial blood gas results: partial pressure of oxygen (PO2), 55 mm Hg, and partial pressure of carbon dioxide (PCO2), 60 mm Hg. When attempting to improve the client’s blood gas values through improved ventilation and oxygen therapy, which is the client’s primary stimulus for breathing?

A

High PCO2

B

Low PO2

C

Normal pH

D

Normal bicarbonate (HCO3)

Question 45 Explanation:

A chronically elevated PCO2 level (above 50 mmHg) is associated with inadequate response of the respiratory center to plasma carbon dioxide. The major stimulus to breathing then becomes hypoxia (low PO2). High PCO2 and normal pH and HCO3 levels would not be the primary stimuli for breathing in this client.

Question 46

Dietary recommendations for a patient with a hypotonic fluid excess should include:

A

decreased sodium intake

B

increased sodium intake

C

increased fluid intake

D

intake of potassium-rich foods

Question 46 Explanation:

Hypotonic fluid volume excess (FVE) involves an increase in water volume without an increase in sodium concentration. Increased sodium intake is part of the management of this condition.

Question 47

Which of the following conditions is associated with elevated serum chloride levels?

A

cystitis

B

diabetes

C

eclampsia

D

hypertension

Question 47 Explanation:

Eclampsia is associated with increased levels of serum chloride.

Question 48

Mr. McPartlin suffered abrasions and lacerations after a vehicular accident. He was hospitalized and was treated for a couple of weeks. When planning care for a client with cellular injury, the nurse should consider which scientific rationale?

A

Nutritional needs remain unchanged for the well-nourished adult.

B

Age is an insignificant factor in cellular repair.

C

The presence of infection may slow the healing process.

D

Tissue with inadequate blood supply may heal faster.

Question 48 Explanation:

Infection impairs wound healing. Adequate blood supply is essential for healing. If inadequate, healing is slowed. Nutritional needs, including protein and caloric needs, increase for all clients undergoing cellular repair because adequate protein and caloric intake is essential to optimal cellular repair. Elderly clients may have decreased blood flow to the skin, organ atrophy and diminished function, and altered immunity. These conditions slow cellular repair and increase the risk of infection.

Question 49

A rise in arterial pressure causes the baroreceptors and stretch receptors to signal an inhibition of the sympathetic nervous system, resulting in:

A

decreased sodium reabsorption

B

increased sodium reabsorption

C

decreased urine output

D

increased urine output

Question 49 Explanation:

Arterial baroreceptors and stretch receptors help maintain fluid balance by increasing urine output in response to a rise in arterial pressure.

Question 50

Aldosterone secretion in response to fluid loss will result in which one of the following electrolyte imbalances?

Etiologies associated with hypocalcemia may include all of the following except:

A

renal failure

B

inadequate intake calcium

C

metastatic bone lesions

D

vitamin D deficiency

Question 51 Explanation:

Metastatic bone lesions are associated with hypercalcemia due to accelerated bone metabolism and release of calcium into the serum. Renal failure, inadequate calcium intake, and vitamin D deficiency may cause hypocalcemia.

Question 52

A 12-year-old boy was admitted in the hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing intervention should be included in the care of plan for the client?

A

Room temperature reduction

B

Fluid restriction of 2,000 ml/day

C

Axillary temperature measurements every 4 hours

D

Antiemetic agent administration

Question 52 Explanation:

For patient with hyperthermia, reducing the room temperature may help decrease the body temperature. Tepid baths, cool compresses, and cooling blanket may also be necessary. Antipyretics, and not antiemetics, are indicated to reduce fever. Oral or rectal temperature measurements are generally accepted and are more accurate than axillary measurements. Fluids should be encouraged, not restricted to compensate for insensible losses.

Question 53

A 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to burn trauma. Which nursing intervention should be included for reducing pain due to cellular injury?

Nursing intervention for the patient with hyperphosphatemia include encouraging intake of:

A

amphogel

B

Fleets phospho-soda

C

milk

D

vitamin D

Question 54 Explanation:

Administration of phosphate binders (amphogel and basagel) will reduce the serum phosphate levels.

Question 55

Nursing interventions for a patient with hypermagnesemia include administering calcium gluconate to:

A

increase calcium levels

B

antagonize the cardiac effects of magnesium

C

lower calcium levels

D

lower magnesium levels

Question 55 Explanation:

In a patient with hypermagnesemia, administration of calcium gluconate will antagonize the cardiac effects of magnesium. Although calcium gluconate will raise serum calcium levels, that is not the purpose of administration. Calcium gluconate does not lower calcium or magnesium levels.

Question 56

Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the client?

A

Sodium level

B

Magnesium level

C

Potassium level

D

Calcium level

Question 56 Explanation:

Diuretics such as furosemide may deplete serum potassium, leading to hypokalemia. When the client is also taking digoxin, the subsequent hypokalemia may potentiate the action of digoxin, placing the client at risk for digoxin toxicity. Diuretic therapy may lead to the loss of other electrolytes such as sodium, but the loss of potassium in association with digoxin therapy is most important. Hypocalcemia is usually associated with inadequate vitamin D intake or synthesis, renal failure, or use of drugs, such as aminoglycosides and corticosteroids. Hypomagnesemia generally is associated with poor nutrition, alcoholism, and excessive GI or renal losses, not diuretic therapy.

Question 57

Marie Joy’s lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated?

A

Positive Trousseau’s sign

B

Positive Chvostek’s sign

C

Tetany

D

Paresthesia

Question 57 Explanation:

In a client with hypocalcemia, a positive Trousseau’s sign refers to carpopedal spasm that develops usually within 2 to 5 minutes after applying and inflating a blood pressure cuff to about 20 mm Hg higher than systolic pressure on the upper arm. This spasm occurs as the blood supply to the ulnar nerve is obstructed. Chvostek’s sign refers to twitching of the facial nerve when tapping below the earlobe. Paresthesia refers to the numbness or tingling. Tetany is a clinical manifestation of hypocalcemia denoted by tingling in the tips of the fingers around the mouth, and muscle spasms in the extremities and face.

Question 58

Khaleesi is admitted in the hospital due to having lower than normal potassium level in her bloodstream. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase?

A

Whole grains and nuts

B

Milk products and green, leafy vegetables

C

Pork products and canned vegetables

D

Orange juice and bananas

Question 58 Explanation:

The client with hypokalemia needs to increase the intake of foods high in potassium. Orange juice and bananas are high in potassium, along with raisins, apricots, avocados, beans, and potatoes. Whole grains and nuts would be encouraged for the client with hypomagnesemia; milk products and green, leafy vegetables are good sources of calcium for the client with hypocalcemia. Pork products and canned vegetables are high in sodium and are encouraged for the client with hyponatremia.

Question 59

Maya, who is admitted in a hospital, is scheduled to have her general checkup and physical assessment. Nurse Timothy observed a reddened area over her left hip. Which should the nurse do first?

A

Massage the reddened are for a few minutes

B

Notify the physician immediately

C

Arrange for a pressure-relieving device

D

Turn the client to the right side for 2 hours

Question 59 Explanation:

Turning the client to the right side relieves the pressure and promotes adequate blood supply to the left hip. A reddened area is never massaged, because this may increase the damage to the already reddened, damaged area. The health care provider does not need to be notified immediately. However, the health care provider should be informed of this finding the next time he is on the unit. Arranging for a pressure-relieving device is appropriate, but this is done after the client has been turned.

Question 60

Lisa, a client with altered urinary function, is under the care of nurse Tine. Which intervention is appropriate to include when developing a plan of care for Lisa who is experiencing urinary dribbling?

A

Inserting an indwelling Foley catheter

B

Having the client perform Kegel exercises

C

Keeping the skin clean and dry

D

Using pads or diapers on the client

Question 60 Explanation:

Kegel exercises, which help strengthen the muscles in the perineal area, are used to maintain urinary continence. To perform these exercises, the client tightens pelvic floor muscles for 4 seconds 10 times at least 20 times each day, stopping and starting the urinary flow. Inserting an indwelling Foley catheter increases the risk for infection and should be avoided. The nurse should encourage the client to develop a toileting schedule based on normal urinary habits. However, suggesting bathroom use every 8 hours may be too long an interval to wait. Pads or diapers should be used only as a resort.

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1. Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is appropriate for maintaining normal bowel function?

Assessing dietary intake

Decreasing fluid intake

Providing limited physical activity

Turning, coughing, and deep breathing

2. A 12-year-old boy was admitted in the hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing intervention should be included in the care of plan for the client?

Room temperature reduction

Fluid restriction of 2,000 ml/day

Axillary temperature measurements every 4 hours

Antiemetic agent administration

3. Tom is ready to be discharged from the medical-surgical unit after 5 days of hospitalization. Which client statement indicates to the nurse that Tom understands the discharge teaching about cellular injury?

“I do not have to see my doctor unless i have problems.”

“I can stop taking my antibiotics once I am feeling better.”

“If I have redness, drainage, or fever, I should call my healthcare provider.”

“I can return to my normal activities as soon as I go home.”

4. Nurse Katee is caring for Adam, a 22-year-old client, in a long-term facility. Which nursing intervention would be appropriate when identifying nursing interventions aimed at promoting and preventing contractures? Select all that apply.

Clustering activities to allow uninterrupted periods of rest

Maintaining correct body alignment at all times

Monitoring intake and output, using a urometer if necessary

Using a footboard or pillows to keep feet in correct position

Performing active and passive range-of-motion exercises

Weighing the client daily at the same time and in the same clothes

5. A 36-year-old male client is about to be discharged from the the hospital after 5 days due to surgery. Which intervention should be included in the home health care nurse’s instructions about measures to prevent constipation?

Discouraging the client from eating large amounts of roughage-containing foods in the diet.

Encouraging the client to use laxatives routinely to ensure adequate bowel elimination.

Instructing the client to establish a bowel evacuation schedule that changes every day.

Instructing the client to fill a 2-L bottle with water every night and drink it the next day.

6. Mr. McPartlin suffered abrasions and lacerations after a vehicular accident. He was hospitalized and was treated for a couple of weeks. When planning care for a client with cellular injury, the nurse should consider which scientific rationale?

Nutritional needs remain unchanged for the well-nourished adult.

Age is an insignificant factor in cellular repair.

The presence of infection may slow the healing process.

Tissue with inadequate blood supply may heal faster.

7. A 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to burn trauma. Which nursing intervention should be included for reducing pain due to cellular injury?

Administering anti-inflammatory agents as prescribed

Elevating the injured area to decrease venous return to the heart

Keeping the skin clean and dry

Applying warm packs initially to reduce edema

8. Lisa, a client with altered urinary function, is under the care of nurse Tine. Which intervention is appropriate to include when developing a plan of care for Lisa who is experiencing urinary dribbling?

Inserting an indwelling Foley catheter

Having the client perform Kegel exercises

Keeping the skin clean and dry

Using pads or diapers on the client

9. Jeron is admitted in the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. Which goal is the most important for the client?

Prevention of fluid volume excess

Maintenance of adequate oxygenation

Education about infection prevention

Pain reduction

10. Mang Rogelio, a 32-year-old patient, is about to be discharged from the acute care setting. Which nursing intervention is the most important to include in the plan of care?

Stress-reduction techniques

Home environment evaluation

Skin-care measures

Participation in activities of daily living

11. Mrs. dela Riva is in her first trimester of pregnancy. She has been lying all day because her OB-GYN requested her to have a complete bed rest. Which nursing intervention is appropriate when addressing the client’s need to maintain skin integrity?

Monitoring intake and output accurately

Instructing the client to cough and deep-breathe every 2 hours

Keeping the linens dry and wrinkle free

Using a foot board to maintain correct anatomic position

12. Maya, who is admitted in a hospital, is scheduled to have her general checkup and physical assessment. Nurse Timothy observed a reddened area over her left hip. Which should the nurse do first?

Massage the reddened are for a few minutes

Notify the physician immediately

Arrange for a pressure-relieving device

Turn the client to the right side for 2 hours

13. Pierro was noted to be displaying facial grimaces after nurse Kara assessed his complaints of pain rated as 8 on a scale of 1 (no pain) 10 10 (worst pain). Which intervention should the nurse do?

Administering the client’s ordered pain medication immediately

Using guided imagery instead of administering pain medication

Using therapeutic conversation to try to discourage pain medication

Attempting to rule out complications before administering pain medication

14. Nurse Marthia is teaching her students about bacterial control. Which intervention is the most important factor in preventing the spread of microorganism?

Maintenance of asepsis with indwelling catheter insertion

Use of masks, gowns, and gloves when caring for clients with infection

Correct handwashing technique

Cleanup of blood spills with sodium hydrochloride

15. A patient with tented skin turgor, dry mucous membranes, and decreased urinary output is under nurse Mark’s care. Which nursing intervention should be included the care plan of Mark for his patient?

Administering I.V. and oral fluids

Clustering necessary activities throughout the day

Assessing color, odor, and amount of sputum

Monitoring serum albumin and total protein levels

16. Khaleesi is admitted in the hospital due to having lower than normal potassium level in her bloodstream. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase?

Whole grains and nuts

Milk products and green, leafy vegetables

Pork products and canned vegetables

Orange juice and bananas

17. Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation. Which nursing intervention is the most appropriate for the client who is subsequently developing respiratory alkalosis?

Administering sodium chloride I.V.

Encouraging slow, deep breaths

Preparing to administer sodium bicarbonate

Administer low-flow oxygen therapy

18. Nurse John Joseph is totaling the intake and output for Elena Reyes, a client diagnosed with septicemia who is on a clear liquid diet. The client intakes 8 oz of apple juice, 850 ml of water, 2 cups of beef broth, and 900 ml of half-normal saline solution and outputs 1,500 ml of urine during the shift. How many milliliters should the nurse document as the client’s intake.

2,230

2,740

2,470

2,320

19. Marie Joy’s lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated?

21. Mang Teban has a history of chronic obstructive pulmonary disease and has the following arterial blood gas results: partial pressure of oxygen (PO2), 55 mm Hg, and partial pressure of carbon dioxide (PCO2), 60 mm Hg. When attempting to improve the client’s blood gas values through improved ventilation and oxygen therapy, which is the client’s primary stimulus for breathing?

High PCO2

Low PO2

Normal pH

Normal bicarbonate (HCO3)

22. A client with very dry mouth, skin and mucous membranes is diagnosed of having dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit?

Assessing urinary intake and output

Obtaining the client’s weight weekly at different times of the day

Monitoring arterial blood gas (ABG) results

Maintaining I.V. therapy at the keep-vein-open rate

23. Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium?

14-year-old Elena who is taking diuretics

16-year-old John Joseph with ileostomy

16-year-old Gabriel with metabolic acidosis

18-year-old Albert who has renal disease

24. Genevieve is diagnosed with hypomagnesemia, which nursing intervention would be appropriate?

Instituting seizure precaution to prevent injury

Instructing the client on the importance of preventing infection

Avoiding the use of tight tourniquet when drawing blood

Teaching the client the importance of early ambulation

25. Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid?

Potassium

Phosphate

Chloride

Sodium

26. Jon has a potassium level of 6.5 mEq/L, which medication would nurse Wilma anticipate?

Potassium supplements

Kayexalate

Calcium gluconate

Sodium tablets

27. Which clinical manifestation would lead the nurse to suspect that a client is experiencing hypermagnesemia?

Muscle pain and acute rhabdomyolysis

Hot, flushed skin and diaphoresis

Soft-tissue calcification and hyperreflexia

Increased respiratory rate and depth

28. Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the client?

Sodium level

Magnesium level

Potassium level

Calcium level

29. Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and a bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse implement?

Instructing the client to breathe slowly into a paper bag

Administering low-flow oxygen

Encouraging the client to cough and deep breathe

Nothing, because these ABG values are within normal limits.

30. A client is diagnosed with metabolic acidosis, which would the nurse expect the health care provider to order?

Potassium

Sodium bicarbonate

Serum sodium level

Bronchodilator

31. Lee Angela’s lab test just revealed that her chloride level is 96 mEq/L. As a nurse, you would interpret this serum chloride level as:

high

low

within normal range

high normal

32. Which of the following conditions is associated with elevated serum chloride levels?

cystitis

diabetes

eclampsia

hypertension

33. In the extracellular fluid, chloride is a major:

compound

ion

anion

cation

34. Nursing intervention for the patient with hyperphosphatemia include encouraging intake of:

amphogel

Fleets phospho-soda

milk

vitamin D

35. Etiologies associated with hypocalcemia may include all of the following except:

renal failure

inadequate intake calcium

metastatic bone lesions

vitamin D deficiency

36. Which of the following findings would the nurse expect to asses in hypercalcemia?

prolonged QRS complex

tetany

petechiae

urinary calculi

37. Which of the following is not an appropriate nursing intervention for a patient with hypercalcemia?

administering calcitonin

administering calcium gluconate

administering loop diuretics

encouraging ambulation

38. A patient in which of the following disorders is at high risk to develop hypermagnesemia?

insulin shock

hyperadrenalism

nausea and vomiting

renal failure

39. Nursing interventions for a patient with hypermagnesemia include administering calcium gluconate to:

increase calcium levels

antagonize the cardiac effects of magnesium

lower calcium levels

lower magnesium levels

40. For a patient with hypomagnesemia, which of the following medications may become toxic?

Lasix

Digoxin

calcium gluconate

CAPD

41. Which of the following is the most important physical assessment parameter the nurse would consider when assessing fluid and electrolyte imbalance?

skin turgor

intake and output

osmotic pressure

cardiac rate and rhythm

42. Insensible fluid losses include:

urine

gastric drainage

bleeding

perspiration

43. Which of the following intravenous solutions would be appropriate for a patient with severe hyponatremia secondary to syndrome of inappropriate antidiuretic hormone (SIADH)?

hypotonic solution

hypertonic solution

isotonic solution

normotonic solution

44. Aldosterone secretion in response to fluid loss will result in which one of the following electrolyte imbalances?

hypokalemia

hyperkalemia

hyponatremia

hypernatremia

45. When assessing a patient for signs of fluid overload, the nurse would expect to observe:

bounding pulse

flat neck veins

poor skin turgor

vesicular

46. The physician has ordered IV replacement of potassium for a patient with severe hypokalemia. The nurse would administer this:

by rapid bolus

diluted in 100 cc over 1 hour

diluted in 10 cc over 10 minutes

IV push

47. Which of the following findings would the nurse exp[ect to assess in a patient with hypokalemia?

hypertension

pH below 7.35

hypoglycemia

hyporeflexia

48. Vien is receiving oral potassium supplements for his condition. How should the supplements be administered?

undiluted

diluted

on an empty stomach

at bedtime

49. Normal venous blood pH ranges from:

6.8 to 7.2

7.31 to 7.41

7.35 to 7.45

7.0 to 8.0

50. Respiratory regulation of acids and bases involves:

hydrogen

hydroxide

oxygen

carbon dioxide

51. To determine if a patient’s respiratory system is functioning, the nurse would assess which of the following parameters:

respiratory rate

pulse

arterial blood gas

pulse oximetry

52. Which of the following conditions is an equal decrease of extracellular fluid (ECF) solute and water volume?

hypotonic FVD

isotonic FVD

hypertonic FVD

isotonic FVE

53. When monitoring the daily weight of a patient with fluid volume deficit (FVD), the nurse is aware that fluid loss may be considered when weight loss begins to exceed:

0.25 lb

0.50 lb

1 lb

1 kg

54. Dietary recommendations for a patient with a hypotonic fluid excess should include:

decreased sodium intake

increased sodium intake

increased fluid intake

intake of potassium-rich foods

55. Osmotic pressure is created through the process of:

osmosis

diffusion

filtration

capillary dynamics

56. A rise in arterial pressure causes the baroreceptors and stretch receptors to signal an inhibition of the sympathetic nervous system, resulting in:

decreased sodium reabsorption

increased sodium reabsorption

decreased urine output

increased urine output

57. Normal serum sodium concentration ranges from:

120 to 125 mEq/L

125 to 130 mEq/L

136 to 145 mEq/L

140 to 148 mEq/L

58. When assessing a patient for electrolyte balance, the nurse is aware that etiologies for hyponatremia include:

water gain

diuretic therapy

diaphoresis

all of the following

59. Nursing interventions for a patient with hyponatremia include:

administering hypotonic IV fluids

encouraging water intake

restricting fluid intake

restricting sodium intake

60. The nurse would analyze an arterial pH of 7.46 as indicating:

acidosis

alkalosis

homeostasis

neutrality

Answers and Rationales

Answer: A. Assessing dietary intake. Assessing dietary intake provides a foundation for the client’s usual practices and may help determine if the client is prone to constipation or diarrhea. Limited physical activity may contribute to constipation due to decreased peristalsis. Turning, coughing and deep breathing help promote gas exchange. Fluid intake should be increased to aid bowel elimination.

Answer: A. Room temperature reduction. For patient with hyperthermia, reducing the room temperature may help decrease the body temperature. Tepid baths, cool compresses, and cooling blanket may also be necessary. Antipyretics, and not antiemetics, are indicated to reduce fever. Oral or rectal temperature measurements are generally accepted and are more accurate than axillary measurements. Fluids should be encouraged, not restricted to compensate for insensible losses.

Answer: C. “If I have redness, drainage, or fever, I should call my healthcare provider.”. Knowledge that redness, drainage, or fever — signs of infection associated with cellular injury — require reporting indicates that the client has understood the nurse’s discharge teaching. Follow-up checkups should be encouraged with an emphasis of antibiotic compliance even if the client feels better. There are usually activity limitations after cellular injury.

Answer: D. Instructing the client to fill a 2-L bottle with water every night and drink it the next day. Adequate fluids and fiber in the diet are key to preventing constipation. Having the client fill a 2-L bottle with water every night and drink it the next day is one method for ensuring the client receives at least 2,000 ml of water daily. The client also should be instructed to drink any other fluids throughout the day. High fiber or roughage foods are encouraged. Laxatives should not be used routinely for bowel elimination. They should be used only as a last resort, because clients may become dependent on them. A regular bowel evacuation schedule should be established.

Answer: C. The presence of infection may slow the healing process. Infection impairs wound healing. Adequate blood supply is essential for healing. If inadequate, healing is slowed. Nutritional needs, including protein and caloric needs, increase for all clients undergoing cellular repair because adequate protein and caloric intake is essential to optimal cellular repair. Elderly clients may have decreased blood flow to the skin, organ atrophy and diminished function, and altered immunity. These conditions slow cellular repair and increase the risk of infection.

Answer: B. Having the client perform Kegel exercises. Kegel exercises, which help strengthen the muscles in the perineal area, are used to maintain urinary continence. To perform these exercises, the client tightens pelvic floor muscles for 4 seconds 10 times at least 20 times each day, stopping and starting the urinary flow. Inserting an indwelling Foley catheter increases the risk for infection and should be avoided. The nurse should encourage the client to develop a toileting schedule based on normal urinary habits. However, suggesting bathroom use every 8 hours may be too long an interval to wait. Pads or diapers should be used only as a resort.

Answer: B. Maintenance of adequate oxygenation. For the client with asthma and infection, oxygenation is the priority. Maintaining adequate oxygenation reduces the risk of physiologic injury from cellular hypoxia, which is the leading cause of cell death. A fluid volume deficit resulting from fever and diaphoresis, not excess, is more likely for this client. No information regarding pain is provided in this scenario. Teaching about infection control is not appropriate at this time but would be appropriate before discharge.

Answer: B. Home environment evaluation. After discharge, the client is responsible for his own care and health maintenance management. Discharge includes assessing the home environment for determining the client’s ability to maintain his health at home.

Answer: C. Keeping the linens dry and wrinkle free. Keeping the linens dry and wrinkle-free aids in preventing moisture and pressure from interfering with adequate blood supply to the tissues, helping to maintain skin integrity. Using a foot board is appropriate for maintaining normal body function position. Monitoring intake and output aids in assessing and maintaining bladder function.. Coughing and deep breathing help promote gas exchange.

Answer: D. Turn the client to the right side for 2 hours. Turning the client to the right side relieves the pressure and promotes adequate blood supply to the left hip. A reddened area is never massaged, because this may increase the damage to the already reddened, damaged area. The health care provider does not need to be notified immediately. However, the health care provider should be informed of this finding the next time he is on the unit. Arranging for a pressure-relieving device is appropriate, but this is done after the client has been turned.

Answer: D. Attempting to rule out complications before administering pain medication. When intervening with a client complaining of pain, the nurse must always determine if the pain is expected pain or a complication that requires immediate nursing intervention. This must be done before administering the medication. Guided imagery should be used along with, not instead of, administration of pain medication. The nurse should medicate the client and not discourage medication.

Answer: C. Correct handwashing technique. Handwashing remains the most effective procedure for controlling microorganisms and the incidence of nosocomial infections. Aseptic technique is essential with invasive procedures, including indwelling catheters. Masks, gowns, and gloves are necessary only when the likelihood of exposure to blood or body fluids is high. Spills of blood from clients with acquired immunodeficiency syndrome should be cleaned with sodium hydrochloride.

Answer: A. Administering I.V. and oral fluids. The client’s assessment findings would lead the nurse to suspect that the client is dehydrated. Administering I.V. fluids is appropriate. Assessing sputum would be appropriate for a client with problems associated with impaired gas exchange or ineffective airway clearance. Monitoring albumin and protein levels is appropriate for clients experiencing inadequate nutrition. Clustering activities helps with energy conservation and promotes rest.

Answer: D. Orange juice and bananas. The client with hypokalemia needs to increase the intake of foods high in potassium. Orange juice and bananas are high in potassium, along with raisins, apricots, avocados, beans, and potatoes. Whole grains and nuts would be encouraged for the client with hypomagnesemia; milk products and green, leafy vegetables are good sources of calcium for the client with hypocalcemia. Pork products and canned vegetables are high in sodium and are encouraged for the client with hyponatremia.

Answer: C. 2,470. The fluid intake includes 8 oz (240 ml) of apple juice, 850 ml of water, 2 cups (480 ml) of beef broth, and 900 ml of I.V. fluid for a total of 2,470 ml intake for the shift.

Answer: A. Positive Trousseau’s sign. In a client with hypocalcemia, a positive Trousseau’s sign refers to carpopedal spasm that develops usually within 2 to 5 minutes after applying and inflating a blood pressure cuff to about 20 mm Hg higher than systolic pressure on the upper arm. This spasm occurs as the blood supply to the ulnar nerve is obstructed. Chvostek’s sign refers to twitching of the facial nerve when tapping below the earlobe. Paresthesia refers to the numbness or tingling. Tetany is a clinical manifestation of hypocalcemia denoted by tingling in the tips of the fingers around the mouth, and muscle spasms in the extremities and face.

Answer: A. Tented skin turgor and thirst. Hypernatremia refers to elevated serum sodium levels, usually above 145 mEq/L. Typically, the client exhibits tented skin turgor and thirst in conjunction with dry, sticky mucous membranes, lethargy, and restlessness. Muscle weakness and paresthesia are associated with hypokalemia; fruity breath and Kussmaul’s respirations are associated with diabetic ketoacidosis. Muscle twitching and tetany may be seen with hypercalcemia or hyperphosphatemia.

Answer: B. Low PO2. A chronically elevated PCO2 level (above 50 mmHg) is associated with inadequate response of the respiratory center to plasma carbon dioxide. The major stimulus to breathing then becomes hypoxia (low PO2). High PCO2 and normal pH and HCO3 levels would not be the primary stimuli for breathing in this client.

Answer: A. Assessing urinary intake and output. For the client with fluid volume deficit, assessing the client’s urine output (using a urometer if necessary) is essential to ensure an output of at least 30 ml/hour. The client should be weighed daily, not weekly, and at same time each day, usually in the morning. Monitoring ABGs is not necessary for this client. Rather, serum electrolyte levels would most likely be evaluated. The client also would have an I.V. rate at least 75 ml/hour, if not higher, to correct the fluid volume deficit.

Answer: D. Albert who has renal disease. Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Clients receiving diuretics, with ileostomies, or with metabolic acidosis may be hypokalemic and should be encouraged to eat foods high in potassium.

Answer: A. Instituting seizure precaution to prevent injury. Instituting seizure precaution is an appropriate intervention, because the client with hypomagnesemia is at risk for seizures. Hypophosphatemia may produce changes in granulocytes, which would require the nurse to instruct the client about measures to prevent infection. Avoiding the use of a tight tourniquet when drawing blood helps prevent pseudohyperkalemia. Early ambulation is recommended to reduce calcium loss from bones during hospitalization.

Answer: D. Sodium. Sodium is the electrolyte whose level is the primary determinant of the extracellular fluid concentration. Sodium a cation (e.g., positively charged ion), is the major electrolyte in extracellular fluid. Chloride, an anion (e.g., negatively charged ion), is also present in extracellular fluid, but to a lesser extent. Potassium (a cation) and phosphate (an anion) are the major electrolytes in the intracellular fluid.

Answer: B. Kayexalate. The client’s potassium level is elevated; therefore, Kayexalate would be ordered to help reduce the potassium level. Kayexalate is a cation-exchange resin, which can be given orally, by nasogastric tube, or by retention enema. Potassium is drawn from the bowel and excreted through the feces. Because the client’s potassium level is already elevated, potassium supplements would not be given. Neither calcium gluconate nor sodium tablets would address the client’s elevated potassium level.

Answer: B. Hot, flushed skin and diaphoresis. Hypermagnesemia is manifested by hot, flushed skin and diaphoresis. The client also may exhibit hypotension, lethargy, drowsiness, and absent deep tendon reflexes. Muscle pain and acute rhabdomyolysis are indicative of hypophosphatemia. Soft-tissue calcification and hyperreflexia are indicative of hyperphosphatemia. Increased respiratory rate and depth are associated with metabolic acidosis.

Answer: C. Potassium level. Diuretics such as furosemide may deplete serum potassium, leading to hypokalemia. When the client is also taking digoxin, the subsequent hypokalemia may potentiate the action of digoxin, placing the client at risk for digoxin toxicity. Diuretic therapy may lead to the loss of other electrolytes such as sodium, but the loss of potassium in association with digoxin therapy is most important. Hypocalcemia is usually associated with inadequate vitamin D intake or synthesis, renal failure, or use of drugs, such as aminoglycosides and corticosteroids. Hypomagnesemia generally is associated with poor nutrition, alcoholism, and excessive GI or renal losses, not diuretic therapy.

Answer: C. Encouraging the client to cough and deep breathe. The ABG results indicate respiratory acidosis requiring improved ventilation and increased oxygen to the lungs. Coughing and deep breathing can accomplish this. The nurse would administer high oxygen levels because the client does not have chronic obstructive pulmonary disease. Breathing into a paper bag is appropriate for a client hyperventilating and experiencing respiratory alkalosis. Some action is necessary, because the ABG results are not within normal limits.

Answer: B. Sodium bicarbonate. Metabolic acidosis results from excessive absorption or retention of acid or excessive excretion of bicarbonate. A base is needed. Sodium bicarbonate is a base and is used to treat documented metabolic acidosis. Potassium, serum sodium determinations, and a bronchodilator would be inappropriate orders for this client.

Answer: D. urinary calculi. Urinary calculi may occur with hypercalcemia. Shortened, not prolonged QRS complex would be seen in hypercalcemia. Tetany and petechiae are signs of hypocalcemia.

Answer: B. administering calcium gluconate. Calcium gluconate is used for replacement in deficiency states. Calcitonin and loop diuretics are used to lower serum calcium.

Answer: D. renal failure. Renal failure can reduce magnesium excretion, leading to hypermagnesemia. Diabetic ketoacidosis, not insulin shock is a cause of hypermagnesemia. Hypoadrenalism, not hyperadrenalism is a cause of hypermagnesemia. Nausea and vomiting lead to hypomagnesemia.

Answer: B. antagonize the cardiac effects of magnesium. In a patient with hypermagnesemia, administration of calcium gluconate will antagonize the cardiac effects of magnesium. Although calcium gluconate will raise serum calcium levels, that is not the purpose of administration. Calcium gluconate does not lower calcium or magnesium levels.

Answer: B. Digoxin. In hypomagnesemia, a patient on digoxin is likely to develop digitalis toxicity. Neither A nor C has toxicity as a side effect. CAPD is not a medication.

Answer: D. cardiac rate and rhythm. Cardiac rate and rhythm are the most important physical assessment parameter to measure. Skin turgor, intake and output are physical assessment parameters a nurse would consider when assessing fluid and electrolyte imbalance, but choice d is the most important.

Answer: B. hypertonic solution. When hyponatremia is severe, hypertonic solutions may be used but should be infused with caution due to the potential for development of CHF. In SIADH, isotonic and hypotonic solutions are not indicated, because urine output is minimal, so water is retained. this water retention dilutes serum sodium levels, making the patient hyponatremic and necessitating administration of hypertonic solutions to balance sodium and water. Normotonic solutions do not exist.

Answer: C. arterial blood gas. Arterial blood gases will indicate CO2 and O2 levels. This is an indication that the respiratory system is functioning. Respiratory rate can reveal data about other systems, such as the brain, making letter c a better choice. Pulse rate is not measure of respiratory status. Pulse oximetry yields oxygen saturation levels, which is not a measure of acid-base balance.

Answer: B. 0.50 lb. Weight loss of more than 0.50 lb. is considered to be fluid loss.

Answer: B. increased sodium intake. Hypotonic fluid volume excess (FVE) involves an increase in water volume without an increase in sodium concentration. Increased sodium intake is part of the management of this condition.

Answer: B. diffusion. In diffusion, the solute moves from an area of higher concentration to one of lower concentration, creating osmotic pressure. Osmotic pressure is related to the process of osmosis. Filtration is created by hydrostatic pressure. Capillary dynamics are related to fluid exchange at the intravascular and interstitial levels.

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